Dialogue therapy in psychosis
2020
Annbjørg Haram
psychologist specialist
Schedule
1. Background & Foundations
2. Theory Perspectives & Attitudes
3. The DT-figure model - Methods
organized in three tables
4. Central findings of analysis from a
local project, Ålesund hospital,
Ålesund
5. Questions
Dialogens kraft 2004
• As in a therapeutic collaboration, the book is structured in three stages. Plans of research is referred to in the preface by Tom Andersen.
• Patients are invited as co-researchers and theirs's statements appear in italics.
• In Cullberg’s book from 2000, pages 191-193, the sketch from the dialogue therapy model and case illustrations from Haram's therapy are shown.
• The dialogue therapy model was first presented by Haram in a family therapy workshop in Asker, 1996.
24.02.2020 3Dialogterapi ved psykose
• and has a pragmatic
attitude to tailor the
treatment to each
person
• key sources of
inspiration are found
in humanistic
traditions
• specific concepts from
language and narrative
approaches, familiy
therapy, intersubjectivity
and mentalization-based
treatments
DT is a philosophical-ethical
approach
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• DT offers a
psychotherapy that
emphasizes the
opportunity for cure
and restoring health
in psychosis
• this type of
highlighting in itself
may promote change
by positively
influencing the
patients’ motivation
Perspectives and Attitudes
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• is to ask how you as the
therapist would like to
be met in a similar
situation, and the
perception that a human
being cannot be
changed from the
outside
• the therapist can only
help the patient to see
opportunities
• and an option to
choose to make use of
them
Characteristics in DT
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• there is an agreement
among several
theories that the
dialogue represents a
powerful landscape of
communicative
processes
• essential in DT is to
move focus from
monologue and
disease thinking to
dialogue and contexts
of causal relationship
Perspectives & Methods
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• a central aspect is
that treatment
questions are dealt
with in dialogue, and
the therapist is not
analyzing behind the
words
• if anything is
interpreted, this is
done together with
the patient and not by
the therapist alone
Essential aspect
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• the dialogue is applied
as a powerful
therapeutic instrument
to open doors into
rooms for free
conversations
• dialogue therapy is
here and now-
oriented and
emphasises use of
curiosity, to wonder;
what do we not
know in what we
know?
The power of the dialogue
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• dialogue therapy has
a strong attitude on
restoring health, with
an emphasis on
contexts
• history and
experiences is
natural, unique and
subjective
• the illness and
healthy properties
are dealt with in
parallel in
psychoterapy
Attitudes & Practice
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• if the disordered parts
are primarily attended
to, this may maintain the
illness and lead to a
chronic disease state
• to be genuine, muster
empathy,
involvement and
• respectful listening to
all utterances are
highlighted
Central perspectives
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• the therapist inspires
to a process of
reciprocity and
emotional self-
development
• a starting point to
empower the patient’s
healthy features is to
create an atmosphere of
safety, inclusion, hope,
dialogue and a
collaborative process
Emotional self-growth
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As in music with interest in
the spaces between the notes
(Steve de Shazer)
• create an atmosphere of safety, inclusion,
hope, dialogue and a collaborative process
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• the therapist is
meeting moments
spontaneously to
promote
opportunities for
positive change
• the therapist
encourages the
patient to find keys to
solutions in fighting
the illness
Stimulate the patient’s own efforts
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Invite the patient into dialogue
• Is there something I should do different ?
• Is there something I forgot to ask you about ?
• So well, how did you do it?
• Empower the patient
• Give compliment
• The therapist wonders, small-talks, tuning in
and seeks advice along the way
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• the therapist has a critical eye on
how language constitutes
attitudes an influences how we
meet the patients
• psychosis is not primarily
regarded as a biological illness
• In spite; a
consequence of
several small or
large life
stresses, trauma,
caused by
identity harm in
interpersonal
relationships
Attitude & Language
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• the patients are invited
to participate in a
collaborative, mutual
relationship with their
own specific
knowledge
• symptoms are considered
as informative in
providing opportunities
to talk and understand
the patient’s history and
causal explanations
Knowledge of their own psychosis
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• experiences from the
psychotic world are
seen as opportunities
for better
understanding of the
patients real life
problems
• small-talk and
frequent summing up
in order to reduce
anxiety and ease the
atmosphere
Reflecting methods – small-talk
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• the patient is assisted to
revise history to see
nuances and sort out
misunderstandings
• this intends to reduce
confusion and feelings of
chaos from the psychosis
• it implies that the
psychotic language
should not be
considered as a single-
sided sign of biological
illness that first of all
must be remediated by
antipsychotic
medication
Sort out misunderstandings
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• instead, symptoms are
seen to involve
deposits or tracks that
give important
information and show
connections to real
life-events
• this implies that to
share the patient's
stories might lead the
psychotic world to
loose its paralyzing
power
New history in dialogue
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• DT is provided in one
hour sessions each
week. It has three
phases, and the length
of treatment usually
varies from three
months to three years
• the therapist goes
along with the
patient and moves
within and between
the different phases,
and, if necessary,
stops and moves
back to previous
phases
Specific Methods of DT
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• focus is on
authorizing the
patients in regaining
self-regulation
(figure1).
• the essence of self-
regulation is to deal
with and master own
emotions and
behavior, which
implies to regain
mental control and
direct focus on one
thing and ignore
others
Methods of DT
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Figure text:
The model in fig. 1 illustrates the patient’s development of self-regulation along with
therapeutic interactions in DT (Haram, 2004). The circle at the top of the model shows the
patient’s degree of symptoms at start of treatment. The hidden circle pictures the patient’s
healthy functioning. The third circle displays the therapist's total competence. The line
between the two circles symbolizes the therapeutic competence in action. The two circles in
the middle of the model symbolize the breakthrough, where the patients have succeeded in
pushing/splitting the symptoms themselves. This step is crucial and opens for the patient’s
gradually co-evolving participation in the dialogue, even if voices or other delusions persist.
The circle second to bottom states that psychotherapy has evolved to a stage where the patient
more fully participates. Finally, the large bottom circle displays the self after changing from
captivity in psychosis to freedom with self-control and direction in life. The small piece of the
hidden circle shows possible remaining symptoms but that no longer are threatening to the
patient.
• initial therapeutic
steps in DT put
weight on creating an
atmosphere of safety
and predictability
• Important elements
are inclusion, hope,
and to invite the
unique patient to a
co-creating treatment
process
Therapeutic Steps of DT
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The clinical themes and specific interventions
in the three phases of DT are specified in
tables 1-3 below
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Table 1. Specific methods in the first treatment phase
Therapeutic theme Central interventions
(1) Create a safe therapeutic
relationship
The therapist small-talks about the situation without necessarily
expecting answers to make herself/himself known and
predictable
(2) Prospects of emotional
knowledge
The therapist is aware of quality moments and moves along with
the emotional flow or the wordless signs to promote development
of emotional growth
3) Impart enthusiasm, tune in
and share language
The therapist tunes into contact with compassion, enthusiasm and
empathy, shares language, varies tone of voice and tonality, is
doing small-talk and asks questions about what comes up in
therapy, invites to dialogue and collaboration
(4) Authenticity and give
response
The therapist seeks resonance, themes and ways of relating
oneself, is authentically committed, and gives responses along the
way in words and in body language
(5) Reduce mystery and fear The therapist assists the patient to sort out mix-ups in the chaos
of psychosis, giving small-talks and summing up to reduce
confusion and mystery, increase safety and calm down the
patient’s fear
(6) Compliment improvements
and give hope
The therapist thinks and communicates prospects of
improvements, nourishing hope and opportunities, and in this
fashion seeks to increase the patient’s sense of freedom and
safety
• the therapist uses
emotional presence
to take hold of good
moments in locating
the appropriate
contact and meeting
point with the patient
• being aware of signals
and utterances, meet
shifting needs - using
interventions such as
small-talk and
reflecting activity
First stage of DT
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Illustrations of therapeutic talks
«I’m glad you decided to meet me here today, even if it’s hard for you to talk; you don’t know me yet and the entire situation can be experienced very intimidating to you; would you like that I start and talk about my experiences as your therapist so that you can get a little familiar with me?; you don’t have to answer me if you don’t feel it naturally; how does that sound to you?; I see how you struggle and understand it might be difficult to find your own voice in the chaos, but you are doing so well, we’ll figure it out together.»
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• the therapist seeks
emotional resonance,
themes and ways of
relating in being
authentically, truly
engaged
• central is the
importance of
intuition, emotional
resonance of an
experience together
with shared
understanding and
reciprocity
Movements in DT
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• encouraging the
patient along the
way in words and in
body language,
emphasizes to use
the patient's
language
• exchange a variety of
perspectives to help
the patient sort out
misunderstandings
caused by symptoms
from the psychotic
world
Reclaim a lost or deficient self
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• the therapist assists
the patient in seeing
connections between
psychotic symptoms
and real life-events,
to reduce fear
• signalize a strong
belief in the patient’s
ability for change to
restore health and
have an enduring
open eye for different
methods that might
be better
Demystifying frightening symptoms
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Clinical vignette: “When admitted, I was
trapped and left alone, which was completely
the opposite of what I needed. Psychiatry stops
asking questions when you’ve got a diagnosis
like schizophrenia.”
• the therapist shows
humility for
unknown elements,
and puts weight on
creating an
atmosphere where
new opportunities
are welcomed rather
than restricted
• visualizes prospects
of improvement,
nourishing hope and
reinforce what works
now and has worked
before to increase the
patient’s sense of
freedom
Humility for the unknown
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Table 1: Baseline demographic characteristics for patients in Dialogue therapy and
Standard treatment
Dialogue
Therapy (n=54)
Standard
Treatment (n=54)
Age, Mean (SD) 29.4 (10.3) 27.9 (9.6)
Female 23 (43 %) 23 (43 %)
Diagnosis (ICD 10)
Schizophrenia (F20.0-9) 24 24
Paranoid Psychoses (F22.0-9) 10 10
Acute Polymorph Psychoses (F23.0-9) 5 5
Schizoaffective Psychoses (F25.0-9) 5 5
Bipolar Affective Disorder (F31.0-9) 5 5
Severe Depression with Psychotic
Symptoms
5 5
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FIGURE 1. GAF SCORES AT BASELINE AND FOLLOW UP FOR PATIENTS IN DIALOGUE THERAPY AND
STANDARD TREATMENT
24.02.2020 37Effect sizes (Cohen’s d) were large; 1.8 for
GAF-S and 2.1 for GAF-F.
Table 2: Changes in GAF scores over the treatment course in Dialogue therapy and
Standard treatment
Baseline Follow-up
Dialogue
Therapy
Standard
treatment
Dialogue
Therapy
Standard
treatment
All patients (n=108, 54 in each treatment group)
GAF-S, mean (SD)
31.2 (9.3) 32.4 (10.2) 74.9 (15.2) 47.5 (13.8)
GAF-F, mean (SD)
32.6 (9.4) 35.0 (10.5) 77.7 (15.6) 47.7 (13.0)
Schizophrenia (n=48, 24 in each treatment group)
GAF-S, mean (SD)
26.8 (9.2) 29.5 (9.3) 75.4 (15.1) 45.4 (12.8)
GAF-F, mean (SD)
28.3 (9.6) 31.6 (8.2) 77.7 (15.5) 44.7 (13.0)
Other psychoses (n=60, 30 in each treatment group)
GAF-S, mean (SD)
34.7 (8.0) 34.7 (10.5) 74.5 (15.6) 49.1 (14.6)
GAF-F, mean (SD)
36.0 (7.9) 37.6 (11.4) 77.3 (16.0) 50.7 (13.7)
* In both t-tests and regression analyses, at follow up, both GAF-S and GAF-F were
significantly (p < 0.001) higher in patients in Dialog Therapy compared to patient in Standard
treatment. In regression analysis, these group differences were not moderated by whether
patients had schizophrenia diagnoses or diagnoses for other psychosis
24.02.2020 38Effect sizes (Cohen’s d) were large; 1.8 for
GAF-S and 2.1 for GAF-F.
Baseline Follow-up
Dialogue
Therapy
Standard
treatment
Dialogue
Therapy
Standard
treatment
All patients (n=108, 54 in each treatment group)
GAF-S, mean (SD) 31.2 (9.3) 32.4 (10.2) 74.9 (15.2) 47.5 (13.8)
GAF-F, mean (SD) 32.6 (9.4) 35.0 (10.5) 77.7 (15.6) 47.7 (13.0)
Schizophrenia (n=48, 24 in each treatment group)
GAF-S, mean (SD) 26.8 (9.2) 29.5 (9.3) 75.4 (15.1) 45.4 (12.8)
GAF-F, mean (SD) 28.3 (9.6) 31.6 (8.2) 77.7 (15.5) 44.7 (13.0)
Other psychoses (n=60, 30 in each treatment group)
GAF-S, mean (SD) 34.7 (8.0) 34.7 (10.5) 74.5 (15.6) 49.1 (14.6)
GAF-F, mean (SD) 36.0 (7.9) 37.6 (11.4) 77.3 (16.0) 50.7 (13.7)
Table 2: Changes in GAF scores over the treatment course in Dialogue therapy and Standard treatment
* In both t-tests and regression analyses, at follow up, both GAF-S and GAF-F were significantly (p < 0.001) higher in patients in Dialog Therapy compared to patient in Standard treatment. In regression analysis, these group differences were not moderated by whetherpatients had schizophrenia diagnoses or diagnoses for other psychosis
24.02.2020 39
FIGURE 2. CHANGES IN GAF SCORES FROM BASELINE TO FOLLOW UP FOR TWO DIAGNOSTIC
SUBGROUPS IN DIALOGUE THERAPY AND STANDARD TREATMENT
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FIGURE 4. USE OF HIGH-DOSE NEUROLEPTICS AT BASELINE AND FOLLOW
UP IN THE TWO TREATMENT GROUPS
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FIGURE 3. USE OF LOW-DOSE NEUROLEPTICS AT BASELINE AND FOLLOW UP IN THE TWO
TREATMENT GROUPS
Figure 1. Schizophrenia and other Psychosis N=108 Months of Therapy
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Figure 2. Schizophrenia Group N=48Months of Therapy
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• the attention is devoted
to expand reciprocity
and collaboration and to
maintain an authentic
predictable therapeutic
relationship
• the patient is helped
to reach a greater
understanding of
own feelings and
thoughts to be able
to control and
regulate emotions,
authorizing identity
and self-regulation
Second part of treatment
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Table 2. Specific methods in the second treatment phase
Therapeutic theme Central interventions
(1) Maintain a safe therapeutic
relationship
The therapist highlights confidence and a trustworthy, predictable
relationship with the patient
(2) Curiosity and the therapist’s
entire competence
The therapist is personally and professionally engaged in parallel,
and shows curiosity in asking questions along these lines; who is
involved in this, when, where and how?
(3) See the whole human being
The therapist seeks contact with parts of the patient’s self that are
not dominated/ overshadowed by the illness
(4) Get in between
The therapist moves attention to the patient’s healthy self-identity
and emotions and assists the patient in generating a
breakthrough/splitting, pushing the symptoms aside to increase
freedom and reciprocity in the dialogue
(5) Restore the self
The therapist authorizes the patient’s healthy identity and gives
compliments to new and previous achievements in life
(6) Personify the symptoms
The symptoms are personified and visualized to be subjects of
joint exploration in psychotherapy
• including the patient
as an active mutual
participant
• providing
possibilities to
influence their own
situation
• awaken the patient’s
interest to engage in
dialogue
• explore new efforts
on their own
A characteristic of DT
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• show curiosity
• ask questions
• widen the
perspective
• let the patient’s
unique history and
experiences influence
the psychotherapy
Central intervention
24.02.2020 47
• the therapist assists
the patient in pushing
aside the symptoms
by holding firm
contact with the
person's healthy
functioning
• the symptoms are
personified, for
example by calling
them “ghosts”, which
provides the patient
with tools to differ
the symptoms out and
into the therapy
Push the symptoms aside
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• the therapist
highlights not losing
sight of the whole
picture of the patient,
in seeing both
healthy properties
and the illness in
parallel
• crucial is to connect
with the part of the
patient’s self that is
not overshadowed by
the illness
• the purpose is to
create a break-
through - a splitting
Create a breakthrough
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• the patient is assisted
to engage in a
broader dialogue in
distinguishing
between the alien
symptoms and
healthy functioning
• the aim is to help the
patient feel freer and
more able to push the
symptoms outside
themselves and split
off the psychotic
world
Engaged in a broader dialogue
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• a central concept in
DT is authentic
commitment and
empathic concern
• support the patients
own talents an build
a sustainable relation
• an essential method is
to personalize the
symptoms in giving
them expression in
drawings, a poem, a
written history or
possible other
utterances
Central Concept & Methods
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• twist and turn the
distorted psychotic
picture to make it
obvious and
understandable
• put light on contexts
and different
explanations
• in such a way promote
a healing process
where the patient can
become free and
obtain normal life
functioning
Essential intervention
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• give ways to deal
with contents from
the psychotic world
and broadening the
understanding of
what has happened
in the person’s life
• the therapist makes
associations and
empowers the
dialogue to revise the
negative influence of
the patient’s
relationship with the
symptoms
Creating new and better
histories and identities
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• assist the patient in a
process of returning
to a normal life in
the family and
community
• make methods become
the patient’s private
instruments / tools
Third part of treatment
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Table 3. Specific methods in the third treatment phase
Therapeutic theme Central interventions
(1) Encourage independence
The therapist emphasizes to maintain a safe relationship with the
patient and seeks to evolve the dialogue to a broader field of
action
(2) Free from burden
The therapist offers the patient opportunities to learn from
theories and methods used in the psychotherapy and develop
insight
(3) Find explanations and re-
authoring lives
The therapist assists the patient to search for causes and
explanations for the illness and to find new histories and ways of
understanding
(4) Support own power
The therapist supports the patients in developing their own efforts
to find back to a meaningful life
(5) Give the patient tools
The therapist provides tools to prevent new illness signs, preserve
self-regulation and mental control
(6) Return to normal life
The therapist encourages the patient to future occupations, such
as starting in a new job or education or other meaningful
activities in the society
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The therapeutic interventions illustrated
above, show ways to inspire the patients to re-
think or re-evaluate their experiences in
psychotherapy. The aim is to increase the
patient’s insight and competence for the
future management of symptoms as well as to
empower healthy properties.
• invite the patient to
have influence upon
decision making
about diagnostic
evaluations and
possibilities of
change during the
treatment process
• inform and explain the
patient about theories
and knowledge used in
therapy
• this intends to prevent
new illness after
psychotherapy
Evaluating changes
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Clinical vignette: “I used four different types of
neuroleptics without any real rehabilitation or
improvement. In fact, I got worse. When the
symptoms no longer were able to generate
fear and tether my feelings, I was not so afraid
as before. I felt my ability to concentrate
improved.”
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Clinical vignette: “When I managed new things
in social connections you often said, how well,
how did you do it, and what did you do? It was
important that you as my therapist showed me
that I could do something myself, and I
remember how you encouraged me all the time.
You took my story seriously and showed clearly
that you were interested in helping me, which
made a great impact on me. I suppressed my
feelings and then the psychosis came over me.
Life was so unbearably painful.”
Links to references
Haram A, Jonsbu E, Fosse R, Skårderud F, Hole T. Psychotherapy inschizophrenia: a retrospective controlled study. Psychosis. (2018) 10:1–12.doi: 10.1080/17522439.2018.1460392
Haram A, Jonsbu E, Hole T, Fosse R. Dialogue Therapy inPsychosis: A Philosophical-Ethical Approach. Nord Psychol. (2019).doi: 10.1080/19012276.2019.1586570. [Epub ahead of print]
Impact of Psychotherapy in Psychosis: A Retrospective Case Control Study
Annbjørg Haram1*, Roar Fosse2, Egil Jonsbu1,3 and Torstein Hole4,5
ORIGINAL RESEARCH
published: 11 April 2019
doi: 10.3389/fpsyt.2019.00204
Frontiers in Psychiatry
https://www.frontiersin.org/journals/psychiatry#about
Haram, A. (2004). Dialogens kraft: Når tanker blir stemmer [The Power of dialogue: When thoughts becomevoices]. Oslo: Universitetsforl.
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